Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy

BACKGROUND: Diagnostic laparoscopy through the right lower abdominal incision following open appendectomy for suspected acute appendicitis may help in making the correct diagnosis in the absence of pathology of the appendix. METHODS: Fourteen patients with a clinical diagnosis of acute appendicitis underwent diagnostic laparoscopy through the right lower quadrant incision after open appendectomy to exclude further pathology in the case of a noninflamed appendix. RESULTS: In 10 of the 14 patients, laparoscopy helped to correct the diagnosis. In two patients, the etiology of the acute right lower abdominal pain remained unclear. In two others, histological examination showed acute appendicitis despite a normal macroscopic appearance. CONCLUSIONS: Diagnostic laparoscopy through the right lower quadrant incision may help to correct the diagnosis in patients who are operated on for clinically acute appendicitis but in whom no acute appendicitis or other pathological findings are seen.     

Ultrasonography in the diagnosis of acute appendicitis

By analysis of as group of 147 patients operated in 1996 at the Surgical Clinic of the Faculty Hospital in Hradec Králové on account of acute appendicitis the author evaluates the importance of ultrasonographic examination for the diagnosis. Its sensitivity was, consistent with data in the literature, 64.1%. US examination is valuable in particular in doubtful clinical diagnosis, the clinical examination remains however the basis in the diagnosis of acute appendicitis.     

Progressive osseous heteroplasia. Report of a family

OBJECTIVES: The purposes of this study were to investigate the use of computed tomography (CT) imaging in patients with suspected acute appendicitis and to evaluate the impact of CT on negative appendectomy and perforation rates. In patients clinically diagnosed of acute appendicitis the reported overall negative appendectomy rate is about 15-20%; 10% in men and 25-45% in women of childbearing age. This is associated with a perforation rate of 21-23%. METHODS: This is a retrospective analysis of 146 consecutive patients presenting with clinical symptoms suspicious of appendicitis over a 2-yr period in whom CT examinations were performed before therapy was instituted. The overall negative appendectomy and perforation rates were calculated for the entire group, as well as for the 54 women aged 15-50 yr in the childbearing cohort. RESULTS: The negative appendectomy rate was 4% in 122 patients operated on and the perforation rate was 22%. Among 36 women 15-50 yr of age operated on, the negative appendectomy rate was 8.3% and the perforation rate was 19%. Surgery was avoided in 24 patients, 18 of whom were women of childbearing age. CONCLUSIONS: The judicious use of CT imaging in patients with equivocal clinical presentation suspected of having appendicitis led to a significant improvement in the preoperative diagnosis. It resulted in a substantial decrease in the negative appendectomy rate compared to previously published reports, without incurring an increase in the perforation rate.     

Acute appendicitis. How many uncorrect diagnosis? A clinical and histological evaluation of 124 cases treated with emergency procedure

Acute appendicitis is a very common disease in western countries, affecting the entire population with higher prevalence in younger people. The diagnosis of the disease is still basically performed through the clinical evaluation of the patient, while peripheral White Cell Count or imaging techniques such as ultrasonography are poorly helpful. Therefore, a great number of patients is operated without finding a severe involvement of the appendix at intraoperative observation. To evaluate the rate of false acute appendicitis and to correlate the histological involvement with the clinical behavior of the disease the Authors carried a prospective study during a period of 28 months on 124 patients with a diagnosis of acute appendicitis treated on emergency basis.     

Yersinia enterocolitica in acute appendicitis, lymphadenitis mesenterialis and regional enteritis (author's transl)]

In 895 patients operated on for acute appendicitis we found Yersinia enterocolitica in 41 cases. Another two cases were detected in postoperative serological examinations. Lymphadenitis mesenterialis was present in 17 cases during operation. Once we detected a regional enteritis. Histological examination of the appendix revealed a purulent inflammation in 21 cases and a phlegmonous-gangrenous inflammation in 4 cases. The other 18 patients suffered from Oxyuriasis, coprostasis or scars of the appendix. For this reason it is impossible to exclude an acute appendicitis in patients with cultural or serological identification of Yersinia enterocolitica.     

Wrong diagnoses of acute appendicitis in women]

In the years 1988 through 1992, 434 patients with acute appendicitis were operated at Third Department of Surgery, Medical Academy, in Kraków. The group included 201 females aged 14 to 90 years of life. In 159 women the diagnosis of acute appendicitis was confirmed, whereas 42 patients were subjected to surgical procedures due to other than appendicitis conditions located within the abdominal cavity. Surgeries prompted by symptoms suggesting appendicitis were most often performed in women with gynecological diseases. Only in several cases laparotomies were performed for other reasons. Wrong diagnoses were most often noted in women below 20 years of life and in the group between 40 and 60 years of life. The introduction of routine ultrasound examinations into the diagnostic management of acute peritonitis and diseases of the reproductive system might result in decrease of the number of diagnostic errors in acute appendicitis in women. An emergency procedure performed when the diagnosis is unclear is recommended rather than prolonged observation. The latter often results in delayed diagnosis of acute appendicitis when diffuse peritonitis develops.     

Diagnostic laparoscopy in 1043 patients with suspected acute appendicitis

OBJECTIVE: To evaluate the efficacy of diagnostic laparoscopy in patients with suspected acute appendicitis, the number of complications associated with the laparoscopic technique, and the effect of leaving a macroscopically normal-looking appendix in place. DESIGN: Three prospective protocols. SETTING: Three departments of surgery, one in Norway and two in Sweden. SUBJECTS: 1043 patients aged 15 years or over. INTERVENTIONS: Diagnostic laparoscopy in patients with signs and symptoms of acute appendicitis who were to be operated on. MAIN OUTCOME MEASURES: Morbidity, mortality, and histological appearance of removed appendices, and outcome whether or not the patient was operated on. RESULTS: 819 patients had appendectomies (61% laparoscopically and 39% by conversion to open operation) with a total complication rate of 10%. In 211 patients a diagnostic laparoscopy was done as a single procedure. There were 181 women in this group and 86 of them had gynaecological disorders. The complication rate was 2% among these 211 patients and after a follow up of two years no patients had been readmitted for appendicectomy. 13 patients were subjected to other open procedures. The overall mortality was 0.4%. CONCLUSION: Diagnostic laparoscopy is safe and can be recommended in patients with suspected acute appendicitis, particularly in women. A macroscopically normal-looking appendix can be left in place.     

The clinical picture of acute appendicitis in children

The authors describe 3860 child patients operated on account of acute appendicitis and analyse the data with regard to age, sex, year of incidence and surgical finding. The highest incidence of acute appendicitis is between 8 and 11 years with a peak at the age of 10 years. It is more frequent in boys (58.3%) than in girls (43.7%), the ratio being 1.3:1. It occurs more often during the cold months (46.5%), in autumn (27.3%) and in winter (25.7%). The number of gangrenous appendicitis is 34.7%-56.7% in boys and 43.5% in girls. The highest rate of missed appendicitis is at the age of the highest incidence (15.2%) with a peak at the age of 10 years (17.8%) and in January (13.3%). The highest incidence of perforated appendicitis is also at the age of the highest incidence (14.9%) with the peak at the age of 8 years (15.6%) and in June (13.5%). Perforation is more frequent in boys (58.1%) than in girls (49.9%). The number of "negative" appendicitis is 15.8%. Prevention of acute appendicitis still remains open due to lack of knowledge of its etiopathogenesis.     

Laparoscopic appendectomy is an acceptable alternative for the treatment of perforated appendicitis

BACKGROUND: Ever since laparoscopy was first applied to the treatment of appendicitis, a controversy has existed as to whether the acknowledged benefits of a minimally invasive approach warrant its preference over the conventional treatment, which historically has had relatively low morbidity. The purpose of this study was to determine if laparoscopic appendectomy should be performed preferentially in cases where surgeons are not limited by technical constraints. METHODS: A retrospective chart review was performed of 112 patients operated on for suspected appendicitis from June 1995 to July 1996. Forty-eight patients underwent laparoscopic appendectomy, and 64 had conventional open appendectomy. Laparoscopic appendectomy was performed using a three-trocar technique and the endoscopic stapler. Results: The histopathological diagnosis of appendicitis was confirmed in 82.6% of cases. Overall, laparoscopic appendectomy reduced length of hospital stay (1.54 versus 4.09 days; p < 0.0001) compared to conventional open appendectomy, with no significant difference in hospital cost ($6430 versus $6669; p = ns). Although the total OR time was longer in the laparoscopic group (75.8 versus 60.2 min; p < 0.0001), laparoscopy resulted in both a reduction in length of stay (2.17 versus 6.27 days; p < 0.0001) and hospital cost ($7506 versus $10,504; p < 0.02) for cases of perforated appendicitis. Conversion to open appendectomy was performed in 6% of patients, all of whom had perforated appendicitis. CONCLUSIONS: Our data suggest that most cases of acute appendicitis with suspected perforation could be managed laparoscopically. Laparoscopic appendectomy significantly reduces length of stay and hospital costs in patients with perforated appendicitis.     

Surgical approach to benign cecal ulcer

Benign cecal ulcer is a rare lesion, usually diagnosed during operation for suspected acute appendicitis or peritonitis of unknown origin. In the past, right hemicolectomy was recommended as the treatment of choice because of the difficulty in differentiating malignant lesions from benign cecal ulcers. However, in recent reports a more conservative approach has been suggested, consisting of selective colectomy followed by frozen section biopsy. This approach is aimed at preventing unnecessary excision of the colon and conserving the ileocecal valve. We present a 47-year-old woman operated for right lower quadrant peritonitis, believed to be due to acute appendicitis. On exploration, a biopsy-proven benign cecal ulcer was found and resected.     

Laparoscopic appendectomy in the adult

AIM OF THE STUDY: The benefits of laparoscopic appendectomy remain controversial. The aim of the study was to evaluate the advantages and disadvantages of this technique. MATERIAL AND METHODS: Four hundred and forty-eight patients operated on for suspected appendicitis during a 5-year period were analysed in a retrospective study. The preoperative diagnosis was corrected in 21.4% of the cases (8.1% for males and 28.7% for females) and the conversion rate was 9.7%. There were 17 patients with generalized peritonitis and 28 with localized peritonitis. During the past year, this surgical method was introduced in another hospital and a prospective study included 92 consecutive patients operated on for appendicitis. The operating time was 53 minutes and the conversion rate was 7.6%. There were five patients with generalized peritonitis and eight with localized peritonitis. RESULTS: There were no postoperative deaths. In the first period, the morbidity rate was 2.3% in the laparoscopic group without conversion. After pathological examination, there was a 14.2% rate of normal appendix. The mean hospital stay was 4.3 days. In the second period, there were only three minor complications and the mean hospital stay was 4.19 days. CONCLUSION: The choice of laparoscopic approach is associated with some advantages: corrections of the diagnosis (mainly in young women) and simplification of the postoperative course, provided that the surgeon has sufficient experience.     

Hypomagnesaemia in postoperative patients: an important contributing factor in postoperative mortality

Nine patients with sickle cell disease (SCD) were operated upon at our hospital for acute appendicitis, comprising only 0.43% of the total appendicectomies performed at our institution. Three appendices were acutely inflamed and six (66.7%) were perforated. Histologic evaluation of the six perforated specimens revealed congestion and haemorrhage by sickled erythrocytes (RBCs) in addition to acute transmural inflammatory cell infiltrates. The mucosa was extensively ulcerated, with haemorrhage both within the lumen and in the appendiceal wall. The blood vessels were dilated and packed with sickled RBCs. Two of the three acutely inflamed appendices showed features of acute transmural appendicitis, with marked congestion and haemorrhage by sickled RBCs. The third did not show any acute inflammatory cell infiltrate, however, the mucosa was partly ulcerated with both mucosal and intraluminal haemorrhage. These findings suggest that acute appendicitis is different in patients with SCD: while it is not common, when it does develop it has a rapid course with a high incidence of perforation due to blockage of appendiceal vessels by sickled RBCs, leading to transmural necrosis.     

Risk factors determining the outcome of a diffuse peritonitis of appendicular genesis in children

The peculiarities of pre-, intra- and early postoperative period course in 108 children, operated on for diffuse and general peritonitis of appendicitis origin, are studied. Most significant 34 prognostic factors for the disease outcome are choosed. The leading factors are the disease course duration, general condition of the patient while hospitalization, the vegetative disorders presence, the intestinal paresis degree, the biochemical inductors of stress contents, the peritoneal exudate character, the kind and composition of microorganisms in it, the character of an early postoperative period course.     

Anaerobic surgical infection

The study covers 125 patients with anaerobic surgical infection, aged 7 to 82 years. Of the total 27 cases are operated for acute cholecystitis, four--diffuse acute peritonitis, seventeen--acute appendicitis, and three--acute hematogenous osteomyelitis. In acute cholecystitis and acute appendicitis microbiological study is carried out of the content, organic wall and periorganic space. In acute cholecystitis patients anaerobic flora is found in 39.01 per cent, and gram-negative--in 44.9 per cent, and in those presenting acute appendicitis--in 28.3 per cent and 58 per cent, respectively. The clinical analysis results point to a severer clinical course in the patients presenting anaerobic flora. The letter becomes manifest as mono infection in 37.2 per cent. It is pointed out that in the presence of two or more signs, characteristic of anaerobic infection, namely: destructive early process, offensive odor and intoxication, anaerobic bacterial flora should be invariably considered. At each microbiological examination the results of staining according to Gram should be also demanded from the laboratory.     

Paratubal cysts in young females as an incidental finding in laparotomies performed for right lower quadrant abdominal pain

Paratubal cysts represent remnants of the paramesonephric or mesonephric duct, the former being more common. Most of them are asymptomatic, but they may rarely give rise to clinical problems due to enlargement or torsion. In this study, we looked for paratubal cysts or other pathological lesions of the right uterine adnexa in young females operated upon for right lower quadrant (RLQ) abdominal pain. Our material consisted of 338 white female patients aged 4-14 years. Laparotomy revealed only acute appendicitis in 283 cases, while 44 had acute appendicitis plus a coincidental paratubal cyst. Most of these cysts were smaller than 1 cm in diameter. However, 2 additional cases had torsion of a large paratubal cyst, while 5 had a ruptured corpus luteum. We suggest that a thorough search of the right adnexa for the presence of paratubal cysts during laparotomies performed for RLQ pain is a useful procedure. This approach also allows detection of other pathological lesions of the right adnexa that often produce symptoms similar to acute appendicitis.     

Low-invasive interventions in abdominal surgery

Low-invasive interventions have now become the usual practice of a surgical unit. Nowadays operations on abdominal and small pelvic organs can be made by using the Russian equipment. In all, more than half the patients with cholelithiasis and its complications, chronic appendicitis, inguinal hernias were operated on by employing video endoscopic equipment (Endomedium, Kazan) and miniaccess-intervention instruments (SAN, Yekaterinburg). The outcomes of surgical treatment are summarized in the paper. The benefits and drawbacks of low-invasive intervention procedures, the advantages of various operation in different groups of patients are dealt with. The feasibility of combined operations and treatment in patients with cholelithiasis is discussed.     

Reoperations in appendicitis

We present our experience in reoperations after appendectomy. From 276 patients were operated for acute appendicitis, we found 70 who presented appendicular abscess, only 13 needed reoperation because of residual abscess, (three cases), evisceration (four cases), and cecum perforation (two cases). All had history of more than four days of preoperative evolution (range 4-45 days) in those eleven patients (six men, and five women) were done 13 reoperations. We had no mortality after successful recovery in all of theme. Our experience in reported from the surgical services of Hospital General de México an Hospital Juárez, both located in México City.     

Tubal pregnancy

139 cases of tubal pregnancy were analyzed from different points of view over a 10-year period. The ratio of tubal abortion to tubal rupture, both as a result of tubal pregnancy, was determined in this sample at 1:1. Between abortion and rupture a clear difference in time lapse was found from the last regular menstruation to the culmination of the specific symptom. The average age of the patients studied was 28 years. 40% were nulliparae, 10% had been operated on for a previous extrauterine pregnancy. From the histories of these patients it was revealed that 14% had previously had adnexitis, although genital tuberculosis is considered to play a subordinate role. 4 cases in which an IUD was present were observed. In 45 cases, the tubal pregnancy was accompanied by appendicitis, although in no cases was the right tube found to be obstructed.     

Duration of antibiotic treatment in surgical infections of the abdomen. Forum statement: a plea for selective and controlled postoperative antibiotic administration

Excessive duration of antibiotics appears to be the principal reason for their inappropriate use in current surgical practice. The main factors to blame are the inability of the clinician to distinguish between contamination and infection, infection and inflammation, and failure to stratify the latter. Consequently, and unnecessarily, prophylactic drugs are carried through into the postoperative period and treatment is continued for long periods. Most experts who contributed to this Discussion Forum favour a trend away from the use of therapeutic courses of fixed duration, and towards attempts to stratify the infective processes, minimising administration by tailoring the duration to the clinical findings. As a consensus of this forum specific recommendations are: Contamination (gastroduodenal peptic perforations operated within 12 hours, traumatic enteric perforations operated with 12 hours, peritoneal contamination with bowel contents during elective or emergency procedures, early or phlegmonous appendicitis or phlegmonous cholecystitis): single dose prophylaxis. Resectable infection (appendicectomy for gangrenous appendicitis, cholecystectomy for gangrenous cholecystitis, bowel resection for ischaemic or strangulated dead bowel without frank perforation): 24 hours postoperative antibiotics. Advanced infection (intra-abdominal infection from diverse sources): 48 hours to 5 days, based on operative findings and patient's condition. Severe intra-abdominal infection with the source not easily controllable (infected pancreatic necrosis, postoperative intra-abdominal infection): longer courses may be necessary.     

Acute appendicitis in early childhood

1728 appendectomies were performed in our institution between the years 1973 and 1978, only 18 of them below the age of 5 years. Acute appendicitis in this age is characterized by a very low incidence (1%); an overwhelming male predominance (8:1), a short history, and a rapid progress of the disease. In 72% perforation of appendix and peritonitis were present at operation. The triad of fever, abdominal pains and vomiting was present in all cases. A high leucocyte count was noted in all cases except one. All patients were operated upon within 16 h of admission. No mortality, a low morbidity and a short hospital stay were recorded.